In traditional Navaho culture, individuals with the physical or behavioral features of both genders are considered “two-spirited” and often arbitrate in marriage disputes because they’re trusted to see both sides of the story. In the broader American culture, though, identifying with a gender different from the one assigned at birth—what we call transgender—is not fully understood or accepted.
That’s changing—slowly. Recent cultural developments—including the rise of transgender characters in TV shows such as “Orange is the New Black” and “Transparent” and the high-profile transitions of celebrities like Bruce Jenner, who is being interviewed by Diane Sawyer on ABC’s 20/20—have brought about a heightened interest and awareness of the transgender population and their journey towards acceptance.
That journey can be especially challenging for transgender teens and young adults, a population with a startlingly high rate of suicide attempts and mental health struggles. We sat down to learn more about transgender youth and adults from one of the leaders in the field, endocrinologist Norman P. Spack, MD, co-director (with Urologist-in-Chief David A. Diamond, MD) of the Gender Management Service (GeMS) program at Boston Children’s Hospital—the first of its kind in the nation.
You’ve said that up to 80 percent of kids who act in a cross-gender way aren’t in fact transgender. How do you distinguish the kids who are experimenting from those who are truly transgender?
Thankfully there’s something that defines who’s the real deal—and that’s their attitude toward puberty. Even the sternest critics will say that, in their experience, when children don’t accept their birthright to the puberty that’s consistent with their sex, then those children are almost certain to be transgender. We can bank on that, but we need to confirm it with the extensive psychological testing that we do.
We have very strict guidelines to get treated by the GeMS program. The kids have to be mentally stable so as to understand the implications of their decisions, they have to have been in counseling for 3 to 6 months, and both parents have to be in agreement that their child should be in the program.
If a child is ultimately accepted for treatment at GeMS, what are the next steps in their journey?
We use puberty suppressants at around age 12. One of the great advantages of the drugs we use is that they’re totally reversible. All we’re doing is delaying puberty. It’s fantastic. It takes the anxiety off.
Around age 14, we begin giving testosterone or estrogen, and our patients go through puberty in the gender they identify with. We vary the age that we start the sex hormones, depending on readiness and how the kid is dealing with the lack of sexual development happening due to the puberty suppressants. At 18, they can have surgery, but that’s only available in a few places like Montreal, Philadelphia and Scottsdale. I think that at some point we won’t have such rigid rules about when you can get your chest flattened. All you have to do is see a girl in a binder with clips all the way from her armpits to her hips. You want to cry for her. Why should I make her wait until she’s 18 when I can relieve her suffering at 14?
You started GeMS in 2007 with a handful of patients. You now have 200 patients. How has the landscape changed since you began this work?
Fortunately, more people are coming around to understanding and accepting transgender youth. There are many transgender characters in television shows, and they’re being presented in a positive light, by and large. Many more people know what the word transgender is, but still not everyone understands it. People tend to confuse sexuality and identity, and often want to conflate these things, but being transgender has nothing to do with sexuality. And there are still those who feel that because 60 to 80 percent of kids who act in a cross-gender way aren’t in fact transgender, that we shouldn’t be encouraging this. This is one of the big debates.
And why do you believe we should be encouraging transgender people to seek treatment?
Forty-five percent of transgender 16- to 25-year-olds who don’t have any support attempt suicide. Even 11 percent of our kids at GeMS come in and tell us they’ve tried to kill themselves, and that’s with the support. The minute these kids even know they’re going to get the puberty suppressants, their suicidal thoughts melt away.
This is very rewarding work. This is an opportunity for all of us to save lives, and really meaningful lives.
Before starting GeMS, you had your own practice treating transgender adults. Are there any fundamental differences between transgender adolescents and adults?
That’s a question that’s very near and dear to me, because I had the unique experience of treating adults before I treated young adolescents at GeMS. The big difference is that the adults lived an entire life in another role before seeking treatment, and in many cases it was not by choice. People acquire attachments—family, friends, a job—and any number of those things can be lifted away from them because of their decision to be something they always felt they were.
In the adults, I found that there were two groups. There were those who knew all along, from childhood, and were either shamed for it or they suppressed it their entire life. These people generally marry and are often superstar athletes and the like. The other group often had a history of psychological problems and substance-abuse issues and in the course of therapy, it started to click that there was something at the root of this.
The under-21-year-olds are just not the same population as the adults. They can’t identify with the adults, but they can identify with Lenore from “Orange is the New Black” because she’s a young woman, so she clearly went through a phase not unlike their own. They look at transgender adults coming out and say, “What were you waiting for'”?
GeMS was the first transgender treatment clinic in the U.S., and there are now over 40 programs across the country. You’re reaching more and more kids and at a younger age. What’s next for this field of medicine?
I think that there is an absolutely tremendous need for tools with which to discern which of the kids are really among the 20 percent who are definitely going to be transgender. With these tools, people could far more freely encourage their kids to act and dress as the gender they identify with, and kids will have a much easier time in school.
These tools are going to be based on analysis from the neck up, not blood levels of anything I can think of—unless it’s maybe a genetic test, but I doubt it. My theory is that we just don’t know enough about the brain. We have such a stake in understanding the brain. I’m convinced that those who would like to make the most significant contribution to medical science in the generation that follows me will make strides in understanding the brain. There have already been a few inferences as to the differences between a male and a female brain not caused by hormones, but they’re somewhat crude. I’m convinced that sooner rather than later, someone’s going to figure something out related to the brains of the 20 percent transgender kids.
Learn more about the Gender Management Service (GeMS) at Boston Children’s.